<div id=tiga_ba>
	<div id=tiga_baa>Tambah Provinsi</div>
	<div id=tiga_bab></div>
	<div class=clear></div>
</div>
            
<form action="utama.php?module=mod_provinsi&act=simpan" onsubmit="return gsValidate('kode|provinsi','Kode Provinsi Harus Diisi|Provinsi Harus Diisi','required_numeric|required');" method="post" enctype="multipart/form-data">
	<table style="margin: 10px 15px 10px 15px;">
		<tr>
			<td>Kode Provinsi</td>
			<td>
				<input name="kode" type="text" class="input_small" id="kode" maxlength="20" />
				<span class="red">*</span>
			</td>
		</tr>
		<tr>
			<td>Nama Provinsi</td>
			<td>
				<input name="provinsi" type="text" class="input2" id="provinsi" maxlength="50" />
				<span class="red">*</span>
			</td>
		</tr>
		<tr>
			<td>Status</td>
			<td>
				<input type='radio' name='status' value='Y' >Aktif
				<input type='radio' name='status' value='N' checked>Tidak Aktif
			</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td><input name="submit" type="submit" class="button" value="Simpan" /></td>
		</tr>
	</table>                
</form>		
            
        